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Maine _______________________ (address of second witness) 4 _______________________________________ (date) ______________________________________________________________________ (printed name of second witness) _____________________________________________________________________________________ (address of first witness) ______________________________________________________________________ (signature of second witness) ______________________________________________________________________________________ (date) ______________________________________________________________________ (printed name of first witness) ______________________________________________________________________________ (signature) SIGNATURES OF WITNESSES ______________________________________________________________________ (signature of first witness) ________________________________________________________________ (address) ______________________________________________________________________ (social security number - optional) (date) ________________________ copy of this form has the same effect as the original. (11) SIGNATURE Sign and date the form here: ______________________________________________________________________ (name) ________________________________________________________________________________________ 3 (city) (state) (zip code) ______________________________________________________________________ (phone) (10) EFFECT OF COPY: A my primary physician: ______________________________________________________________________ (name of physician) ______________________________________________________________________ (address) __________________________ (phone) (Optional) If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following physician as___________________________________________ (address) ______________________________________________________________________ (city) (state) (zip code) _______________________________________________IAN (Optional) (9) I designate the following physician as my primary physician: ______________________________________________________________________ (name of physician) ___________________________s, or ___ I give only the following organs, tissues or part: (8) MY GIFT IS FOR THE FOLLOWING PURPOSES: (i) Transplant (ii) Therapy (iii) Research (iv) Education PART 3 DESIGNATION OF PRIMARY PHYSIC_______________________________________________________________ (add additional pages if needed) 2 PART 2 DONATION OF ORGANS AT DEATH (7) UPON MY DEATH: ___ I give any needed organs, tissues or part6) OTHER HEALTH CARE INSTRUCTIONS OR WISHES: ________________________________________________________________________ ________________________________________________________________________ _________rt, I nominate the agent designated in this form. If that agent is not willing or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated. (ox. If I mark this box, my agent's authority to make health care decisions for me takes effect immediately. (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a couHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following bisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my persona l values to the extent known to my agent. (4) Wtorney for health care, any instructions I give in Section II of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown my agent shall make health care dec and hydration and all other forms of health care to keep me alive, except as I state here: (3) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of at___________ (home phone) (work phone) (2) AGENT'S AUTHORITY: My agent is authorized to make all health-care decisions for me, including decisions to provide, withhold or withdraw artificial nutrition_______________________________ (address) ______________________________________________________________________ (city) (state) (zip code) ___________________________________________________________re decision for me, I designate as my second alternate: ______________________________________________________________________ (name of second alternate agent) ______________________________________________________________________ (home phone) (work phone) 1 If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably available to make a health ca___________________________________________________ (address) ______________________________________________________________________ (city) (state) (zip code) _______________________________________ble to make health care decisions for me, I designate as my alternate agent: ______________________________________________________________________ (name of first alternate agent) _____________________________________________________________________________________ (home phone) (work phone) (Optional) If I revoke the authority of my agent or if my agent is not willing, able, or reasonably availaname of agent) ______________________________________________________________________ (address) ______________________________________________________________________ (city) (state) (zip code) ____RNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I appoint the following person as my agent to make health care decisions for me: ______________________________________________________________________ (egarding the designation of your primary physician. You may complete or modify all or any part of the following form or use a different form. ____________________________________ PART 1 POWER OF ATTO. You also have the right to name someone else to make health-care decisions for you. This form lets you name someone else to make health-care decisions for you. It also lets you express your wishes rthese forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com POWER OF ATTORNEY FOR HEALTH CARE EXPLANATION You have the right to give instructions about your own health careyou should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. The purchase and use of from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document Information Maine Power Of Attorney For Health Care This package contains the Maine Power Of Attorney For Health Care. These forms are not intended and are not a substitute for legal advice. Laws vary Maine